GW1-2022-00026_Well Construction - GW1_20221219

4
WELL CONSTRUCHON RECORD Farlatamf U=ONLY:
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1.Wen Contractor Information:
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2.Well ConstrOcGon Pam t#: � / —' t/ a- /ice >z '/ m 5 'f
Lutd 1wileoble vr!lp m-ds amComtry.Stale vml-=lajerllaa,d¢)
3.Well use )-•me cheekwell /l7 rc % sc-t i' ' -s c�h 4 /
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WatsrSDpplyWen: FROM ITO DretiMM I SLOWS E I TMKWU 5 MAMMAL
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13Gcothermal(HcAmjP,Coolm$Supply) OResidential Wat-Swly(smgta) R s �-
�IndushiaUCommeecial EIResidential WaterSupply(shared) IL GROUT
_ FROM TO ➢TA;1 I 22MMA®r@lr6lEMD&ABrOUNr
Non-Wate rsupply Welk !� >z � � 1 4(L
E �g� OReco`rery' % ft.
InlE AquifaRmharge DGmmtdwaterRemediatica 19 SANDIGRAVBJ.PACK d
Ii"m TO MA irM MOD
OAquiferStomgeandRecavery pSalinityBarrier-- i
ElAguiferTest MormwderDiainage R l /
p6cpetimental Tedmology I1Subsidence Control.
20.DRUJM(;1iAG atmdtadddomi if
OG mat(Closed Loop) OTrd= FROM To nF�nont mto� >war odc :o:.ea
pGeothtxmal'(HeatiiugJCoolirigRelum)'= 930ther(e'Rphtimmider#211twm1 s) R 1. . I •` , .
4.Date Well s ►ell ID# - i2 sl 7
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G:Ts(are)thew sx ent or OTemporary By skwg d rfanv.I keneby unify tym the inn(:) aoruaucted is—rdw—
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tepmrzun&r Zl neamtJECseman oron&eh z*of fdsfon L 23-Site diagram or additional wen defy
/ Yon may vise the back of this page to piovide adds-damal well site details or well
&Number ofwdis eousbucted: construction detmis You may also attach addit®a1 pages if necessary..
Formahlprchg Wonarmmwxwmgpl,wd&OMPwft:kdws=wcmnb�mrym+am I, •--
sabmitoaefmm SUBIVIITPALEMIUMONS
9 Total well depth belowland tmrfjt= / % (ft) ,W:For All Wefts: Submit this,form within 30.days of compttdion of well.
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1¢"Stptic water.level blow itrp of .;..... (il:) D. .. of stet . ri PineesvngUrrif;
Jfwaterfeveltsoboveoaan�_rrre-:t^ _ _... _ tvi_R8lefglrs - - _
rv�ron W Reso ormatzo
. _. -_. .. .._.. ' •,l617 ManServrc`e'Cm NC27699-I617...
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IL Borehole dwmeter. riD.) :14tL far f4eidon Wells Yiti addition to sending itie form io Uie address in
{s 24aabove;also sobmR.a'copy-of thus foim within 10 days.of.compteuon of-yell
l2.WeII ooaatraedan meafrod:. - _ Z _. 'o�shudionto thefoitawm
(ie.ai�c;•rWatyca6k.d'uocrpmb,dc.) .e.. _ . ,
Divisoa of WatrsfResoazts,Undaggio�d Injection_Contivl Pmgram
FORWATER'SUPYLX WELLS ONLY: - " '" _. I636 Mal Service Centr ,RdeW4NC27699-I636
13a.Yield(gpap � /<!5 v' 113etkod of tesh 5E7 Cl/ 24r.For Water Supply&IDiection WeRs:
U
/�/ J I Also submit one copy-of this form within 30 daysofcompietionof
13b.Didn�n type e/(/� AmooaE Z/ well construction to the county bean aIepartment of the county where
meted.
F®GW-t NarthCuoi®Depanncutofr=monmartmedNaunwResm=cs-Dnnim'otWw=R Revi=dAogja 2013